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Objective. To determine geographic variation in urban American Indian and Alaska Native (AI/AN) rates of infant mortality, low birth weight, prenatal care use, and maternal-child health care service availability. Methods. This was a retrospective cohort study using data from the 1989 to 1991 birth-death linked database from the National Center for Health Statistics. We examined births from metropolitan areas with a minimum of 300 AI/AN births during the study period. Key outcomes of interest included rates of low birth weight, neonatal mortality, postneonatal mortality, and women receiving inadequate prenatal care using the modified Kessner index. To determine the type of health services tailored to AI/AN mothers residing in these urban areas, we conducted a telephone survey of the 36 urban Indian health programs operating in 1997 using a semistructured survey. Items in the survey included questions about the availability of prenatal and infant health care. Results. During the 1989 to 1991 study period, there were 72 730 singleton births to AI/AN mothers and/or fathers residing in urban areas, representing 49% of all AI/AN births in the United States. Overall 14.4% of urban AI/AN births were to women who received inadequate care during pregnancy, 5.7% of pregnancies resulted in low birth weight infants, and 11.0 infants died per 1000 live births. Death rates for the neonatal period (5.5 per 1000 births) and postneonatal period (5.4 per 1000 births) were similar. Marked disparity in these indicators exist between pregnancies to AI/AN and white women. Among the 54 metropolitan areas, 46 had a rate ratio (AI/AN: white) for inadequate care of ≥1.5 (range: 0.9-8.5). The mean rate ratios for neonatal and postneonatal mortality were 1.6 (range: 0.3-4.0) and 2.0 (range: 0.5-5.5). There was also considerable geographic variation of AI/AN mortality rates between metropolitan areas in all of the outcomes studied. All of the 20 metropolitan areas with the highest... [ABSTRACT FROM AUTHOR]

We use prescription of statin medications and prescription of warfarin to explore the capacity of electronic health record data to (1) describe cohorts of patients prescribed these medications and (2) identify cohorts of patients with evidence of adverse events related to prescription of these medications. This study was conducted in the WWAMI region Practice and Research Network (WPRN)., a network of primary care practices across Washington, Wyoming, Alaska, Montana and Idaho DataQUEST, an electronic data-sharing infrastructure. We used electronic health record data to describe cohorts of patients prescribed statin or warfarin medications and reported the proportions of patients with adverse events. Among the 35,445 active patients, 1745 received at least one statin prescription and 301 received at least one warfarin prescription. Only 3 percent of statin patients had evidence of myopathy; 51 patients (17% of those prescribed warfarin) had a bleeding complication. Primary-care electronic health record data can effectively be used to identify patients prescribed specific medications and patients potentially experiencing medication adverse events.

Introduction: An estimated 2.4 million people in the United States live with hepatitis C. Though there are effective treatments for chronic hepatitis C, many infected individuals remain untreated because 40% to 50% of individuals with chronic hepatitis C are unaware of their hepatitis C status. In 2013, the United States Preventive Services Task Force (USPSTF) recommended that adults born between 1945 and 1965 should be offered one-time hepatitis C screening. The purpose of this study is to describe rates of birth cohort hepatitis C screening across primary care practices in the WWAMI region Practice and Research Network (WPRN). Methods: Cross-sectional observational study of adult patients born between 1945 and 1965 who also had a primary care visit at 1 of 9 participating health systems (22 primary care clinics) between July 31, 2013 and September 30, 2015. Data extracted from the electronic health record systems at each clinic were used to calculate the proportion of birth cohort eligible patients with evidence of hepatitis C screening as well as proportions of screened patients with positive hepatitis C screening test results. Results: Of the 32 139 eligible patients, only 10.9% had evidence of hepatitis C screening in the electronic health record data (range 1.2%-49.1% across organizations). Among the 4 WPRN sites that were able to report data by race and ethnicity, the rate of hepatitis C screening was higher among African Americans (39.9%) and American Indians/Alaska Natives (23.2%) compared with Caucasians (10.7%; P < .001). Discussion: Rates of birth cohort hepatitis C screening are low in primary care practices. Future research to develop and test interventions to increase rates of birth cohort hepatitis C screening in primary care settings are needed.

Purpose: In the United States, 69% of adults are overweight or obese, as defined by a body mass index (BMI) ≥25 kg/m(2). The US Preventive Services Task Force recommends screening all adult patients for obesity and referring obese patients to intensive, multicomponent behavioral weight loss programs comprising 12 to 26 yearly sessions. The objective of this study is to determine the degree to which overweight and obese primary care patients report willingness to participate in these intensive weight loss programs and to identify the patient factors associated with reported willingness to participate., Methods: This 2013 cross-sectional survey was offered to all adult patients seen for an office visit at 1 of 12 primary care clinics in the Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) Region Practice and Research Network (WPRN). Patients self-reported both their health information and their willingness to participate in a comprehensive weight loss program. Respondents were characterized by descriptive statistics. We compared reported rates of willingness to participate by patient factors and assessed which patient factors were independently associated with reported willingness using bivariate analysis and logistic regression, respectively., Results: Of overweight and obese respondents, 63% reported willingness to participate in comprehensive weight loss programs. Age, sex, race/ethnicity, insurance status, BMI, and reason for wanting to lose weight were all significantly and independently associated with reported willingness to participate., Conclusions: Reported willingness to participate in comprehensive weight loss programs suggests that additional resources are needed to understand strategies for disseminating and implementing effective comprehensive weight loss programs., Competing Interests: Conflicts of Interest: None declared., (© Copyright 2016 by the American Board of Family Medicine.)

Practice-based research networks bring together academic researchers and primary care clinicians to conduct research that improves health outcomes in real-world settings. The Washington, Wyoming, Alaska, Montana, and Idaho region Practice and Research Network implemented a health data-sharing infrastructure across 9 clinics in 3 primary care organizations. Following implementation, we identified challenges and solutions. Challenges included working with diverse primary care organizations, adoption of health information data-sharing technology in a rapidly changing local and national landscape, and limited resources for implementation. Overarching solutions included working with a multidisciplinary academic implementation team, maintaining flexibility, and starting with an established network for primary care organizations. Approaches outlined may generalize to similar initiatives and facilitate adoption of health data sharing in other practice-based research networks.

Background: Increasing diabetes, hypertension, and hypercholesterolemia rates expose some young women to medications with potential adverse fetal effects, such as angiotensin-converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), and statins. This study examined whether quality improvement (QI) interventions promote informed consent and contraception to minimize risks with use of ACE-I/ARB/statins., Methods: This longitudinal cohort study at 7 clinics abstracted medical records of 328 women aged 18 to 44 with ≥1 prescription for ACE-I/ARB/statins and ≥1 visit for hypertension, diabetes, or hypercholesterolemia during the previous year. We measured informed consent documentation and contraceptive methods before and after QI interventions in which providers contacted their patients to discuss medication risks and benefits., Results: Of 179 women who were not surgically sterilized, only 11.7% had documented informed consent related to the risks of ACE-I/ARB/statin use. One hundred fifty-eight women were eligible for the QI intervention (not surgically sterilized, no documented informed consent); only 76 (48.1%) received the intervention. Before the intervention, 23.7% of these 76 were "at risk" of an adverse fetal effect. After the intervention, only 7.9% (P ≤ .001) were "at risk" because some women started contraception, discontinued ACE-I/ARB/statins, or changed drug class., Conclusions: Women prescribed ACE-I/ARB/statins were not consistently using contraception or were not consistently informed of the risks. Provider-implemented QI interventions improved care but were difficult to accomplish, suggesting that new interventions are needed.

Purpose: This study examines how a wide range of supports and obstacles are associated with the medical school admissions process of American Indians and Alaska Natives (AI/ANs), an under-studied population., Method: All AI/AN applicants to the University of Washington School of Medicine during the 2002-2004 admissions cycles were sent a mail-in survey with numerical and open-ended items. We analyzed admissions data for all 107 applicants and data on supports and obstacles for 34 survey respondents., Results: Compared with respondents accepted by at least one medical school, rejected respondents were older, more often were parents, submitted fewer applications, and reported receiving less support for the medical school application process. Obstacles included difficulty with the Medical College Admission Test, insufficient finances, and poor information about the process., Conclusion: A conceptual framework that considers both supports and obstacles in the medical school application process will improve our understanding of the needs of AI/AN applicants.

Background: American Indians and Alaska Natives (AI/ANs) remain underrepresented in the medical profession. This study sought to understand the supports and barriers that AI/AN students encountered on their path to successful medical school entry., Method: The research team analyzed qualitative semistructured, one-on-one, confidential interviews with 10 AI/AN medical students to identify salient support and barrier themes., Results: Supports and barriers clustered in eight categories: educational experiences, competing career options and priorities, health care experiences, financial factors, cultural connections, family and friends, spirituality, and discrimination. Some of the most notable findings of this study include the following: (1) students reported financial barriers severe enough to constrain participation in the medical school application process, and (2) spirituality played an important role as students pursued a medical career., Conclusion: Promoting AI/AN participation in medical careers can be facilitated with strategies appropriate to the academic, financial, and cultural needs of AI/AN students.

Objective: To describe perinatal outcomes and maternal characteristics among American Indian/Alaska Native (AI/AN) women with diabetes in pregnancy., Study Design: A retrospective analysis of live births to AI/AN, African American and white women with diabetes (242,715) during pregnancy for the 1989-1991 period (latest available at the time of study) was conducted utilizing a linked birth/infant death database from the National Center for Health Statistics. AI/AN perinatal outcomes and maternal characteristics were compared to those of African American and white women. Similar analyses compared urban and rural AI/AN populations., Results: AI/AN women were more likely than white women to receive inadequate prenatal care (10.4%), to have higher rates of pregnancy-induced hypertension (9.1%) and to have significantly lower rates of primary cesarean delivery (16.9% vs. 22.3%). The rate of macrosomia among births to AI/AN women (24.2%) was notably higher as compared to that in the white population (17.9%). Rates of musculoskeletal and chromosomal anomalies were also higher among AI/AN women, 9 and 4, respectively, per 1,000 live births, as compared to 6 and 2 per 1,000 for the white population., Conclusion: Multiple maternal risk factors and birth outcomes demonstrate the need for further research to evaluate methods of improving care in this population.

Objectives: We sought to provide a national profile of rural and urban American Indian/Alaska Native (AI/AN) maternal and infant health., Methods: In this cross-sectional study of all 1989-1991 singleton AI/AN births to US residents, we compared receipt of an inadequate pattern of prenatal care, low birthweight (< 2500 g), infant mortality, and cause of death for US rural and urban AI/AN and non-AI/AN populations., Results: Receipt of an inadequate pattern of prenatal care was significantly higher for rural than for urban mothers of AI/AN infants (18.1% vs 14.4%, P